Watch Out for “Loud” Symptoms

My emergency psychiatry mentor, Doug Puryear, was obsessed with broken cigarettes and coffee grounds. He had all the residents and students test for cranial nerve I and olfactory impairment by presenting one or the other to a blindfolded patient. We picked up a few frontal tumors at Puryear’s behest. Medical education emphasizes looking for the “soft signs” (the assymetrical reflex, the visual field cut, impaired digit span, dysgraphia, etc). Our core clinical skills involve reinterpreting the obvious and looking for subtleties, whether in neuropsychiatry or psychotherapy.

Too often we do not discuss, much less think about, the opposite of soft signs: “loud” symptoms. Loud symptoms are impossible to miss: the obvious, bad-breath-in-your-face, listen-to-me-dammit symptoms. Psychiatrists are unnecessary in the recognition of loud symptoms—anyone can recognize them: psychomotor agitation, perseveration, stealing, assaults, lying, failure to follow through with parental obligations, angry outbursts, molestations, suicide attempts, grandiose delusions, panic attacks, conversion paralysis, intoxications. The list of loud symptoms in psychiatry is long.

Loud symptoms, however, can be misleading in diagnosis and in treatment.1 We have also been trained to look beneath the loud symptom and consider, for instance, the shame or fear that underlies the patient’s anger. Olfactory hallucinations can reflect a frontal lobe tumor. The doctor’s role has always been to go beyond the obvious and to detect the subtle determinants.

Since DSM-III, the architects of the manual have elected to write user-friendly diagnostic criteria that require a minimum amount of inference, and too often, minimal training to elicit and to interpret. By accident or by intention, the DSMs (since III) have prominently featured loud symptoms as core diagnostic criteria, and some categories are largely defined by loud symptoms. Think of conduct disorder, the paraphilias, antisocial personality disorder, factitious disorders, dissociative disorders, and impulse-control disorders.

A diagnostic category built around loud symptoms is a set-up for massive comorbidities, as in the case of conduct disorder,2 the paraphilias,3 and impulse-control disorders.4 In these cases, loud symptoms are non-specific symptoms that cast too wide a net.

At other times, loud symptoms lead one to assume they are the most clinically important symptoms. Think of the validity problems associated with antisocial personality disorder compared with the more subtly described—and more validly constructed—psychopathy.5 In other cases, loud symptoms are stand-ins for a limited knowledge base of the phenomenology and clinical features of the disorder—namely, paraphilias, factitious disorders, and the dissociative disorders. The debate about pediatric bipolar disorder versus temper dysregulation disorder in children could be construed as one about the nosological role and importance of loud symptoms.6

As clinicians and DSM-5 nosologists, we should be wary of bedazzlement by loud symptoms and dig deeper for the more profound and subtler findings that lead us to effective understanding and intervention.